POST FORM

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POST FORM

• How does this affect me?

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Tennessees Health Care Decision Act

• In 2004, the Health Care Decision Act was passed
  thus revising Tennessee law concerning health
  care decision making.

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What does this act do?

• Protects patients right to make own health care
  decisions
• Promotes Advance Directives
• Reduces court involvement
• Defines legal protection for those who uphold

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Types of Advance Directives

• Durable Power of Attorney for Health
  Care/Appointment of Health Care Agent
• Living Will/Advance Care Plan
• POST form/ Universal DNR

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How POST form came about?

• Tennessee needed one form to address DNR and
  other resuscitative services
• Tennessee needed one form utilized by all
  healthcare entities in the state i.e. EMS,
  Nursing Homes, Hospitals, etc.
• Tennessee needed a universal form which could
  travel and be recognized across state lines

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Purpose of POST

• To provide a mechanism to communicate patients
  preferences for end-of-life treatment across
  treatment settings
• To improve implementation of advance care planning

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Basis of POST

• Encourages discussion with patient and family or
  surrogate decision maker of key end-of-life care
  issues

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Impact of Tennessee Law

• Acknowledged Universal Do Not Resuscitate Order
• Means a written order that applies regardless of
  the treatment setting and that is signed by the
  patients physician which states that in event
  the patient suffers cardiac or respiratory
  arrest, cardiopulmonary resuscitation should not
  be attempted.
• The law also indicated the Board for Licensing
  Health Care Facilities shall promulgate rules and
  create forms regarding procedures for the
  withholding of resuscitative services from
  patients
• lead to creation and development of POST form
  which was approved as a MANDATORY FORM on
  February , 2006 by the Board for Licensing
  Health Care Facilities
• T.C.A. 68-11-224 (e), (5) (i), (1)

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What is POST?

• POST Physician Orders for Scope of Treatment
• What purpose POST form serves
• Standardized form containing orders by a
  physician who has personally examined a patient
  regarding that patients preferences for end of
  life care
• Complements, but does not replace Appointment of
  Health Care Agent /or Living Will/Advance Care
  Plan
• Effective immediately upon order written and when
  all requirements met
• Requirements for valid POST
• Patients name and signature (Patient signature
  optional according to facility policy)
• Orders
• Physicians signature (MD/DO)
• Basis for orders

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POST Form Description

• POST Form format
• Top of Form
• Explanation of form
• Any section of form not completed indicates full
  treatment for that section
• When need occurs, first follow orders, then
  contact physician
• Patients Name/DOB

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POST Description cont.

• POST Format cont.
• CPR Code or No Code?
• Level of intervention (i.e. comfort care only,
  intermediate care, or full tx)
• Comfort care level stipulates Not to be
  hospitalized unless comfort interventions in the
  present setting fail as applicable to the
  facility patient/resident is located in
• Use or withholding of antibiotics and feeding
  tubes

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POST Description cont.

• POST Format cont.
• Check 1 box each section
• SECTION A Code Status
• Resuscitate or
• Do Not Attempt Resuscitate
• If neither is marked, patient is to be
  resuscitated

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POST Description cont.

• POST Format cont.
• Section B
• Medical Interventions
• Comfort Interventions Treat with dignity and
  respect. Keep clean, warm, dry. Use medication
  by any route, positioning, wound care other
  measures to relieve pain/suffering. Use oxygen,
  suction, manual tx of airway obstruction as
  needed for comfort. Do not transfer to hospital
  for life sustaining tx. Transfer only if comfort
  needs cannot be met in current location.
• Limited additional Interventions Includes care
  described above. Use medical tx, IV fluids and
  cardiac monitoring as indicated. Do not use
  intubation, advanced airway interventions, or
  mechanical ventilation. Transfer to hospital if
  indicated. Avoid intensive care.

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POST Description cont.

• POST Format cont.
• Full TX/Resuscitation All above plus CPR,
  intubation, defibrillation
• Other instructions_______________

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POST Description cont.

• POST Format cont.
• Section C Antibiotics
• Treatment for new medical conditions
• No antibiotics
• Antibiotics
• Other instructions____________

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POST Description cont.

• POST Format cont.
• Section D Medically Administered Fluids
  Nutrition
• No IV fluids
• IV fluids for a defined trial period
• IV fluids long term
• No feeding tube
• Feeding tube for a defined trial period
• Feeding tube long term
• Other instructions__________

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POST Description cont.

• POST Format cont.
• Where does the Physician Sign?
• Section E
• By a physician who has examined the patient
  (Mandatory)
• Discussed with.
• Physicians printed Name/Phone
• Basis for Orders
• Patients preferences
• Patients best interest (Patient lacks capacity
  or preferences unknown)
• Medical indications
• Other (specify)

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POST Description cont.

• POST Format cont.
• Back of Form
• Required Signatures
• Patient/legal rep, surrogate (Patients signature
  is optional according to facility policy)
• Person preparing form
• Title/phone number/date
• Directions for Health Care Professionals
• Completing POST
• Using POST
• Reviewing POST

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Who Can Fill Out POST Form?

• Physician
• Social Worker experienced in a health care
  setting
• Nurse
• MD signs regardless who completes and must
  discuss form and contents with patient/responsible
  party

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Need POST if has DNR Order?

• POST addresses more than just DNR -
• Addresses
• Comfort level
• IVs/Nutrition
• Antibiotics
• Documents what individual was involved in
  discussion
• Signature of pt, parent, or guardian or Health
  Care Agent

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POST if for

• Seriously ill patients
• Terminally ill patients
• chronic, progressive disease/s

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Is POST required on all patients?

• NO
• Voluntary
• Specifically focuses on medical treatment patient
  does or does not want at end of life

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What if Patient already has Advance Directive?

• POST reinforces wishes expressed in advance
  directive
• POST is a physicians order that should be
  immediately used to direct the care of the
  patient
• Recommend very ill patients have both, POST
  Advance Directive

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Need DNR order if have POST?

• POST serves as the DNR order

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When Should Form be Reviewed?

• When patient is transferred from one health care
  facility to another
• Facility initiating transfer must communicate the
  existence of POST form to receiving facility
  PRIOR to transfer (POST form must accompany the
  patient to the receiving facility)
• POST orders remain in effect in receiving
  facility
• After admission, attending MD should review a
  healthcare professional should initial POST
• If patients condition significantly changes,
  such as
• Close to death
• Extraordinary suffering
• Improved condition
• Advanced progressive illness
• Permanent unconsciousness
• When patients preferences change

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Changing the POST Form

• Void the form complete a new one
• How to Void the POST
• Draw a line through the Physician Orders
• Write the word VOID in large letters, then
• Sign or initial the form
• After voiding the form, a new form may be
  completed leave VOIDED form in permanent record
• If no new form is completed, full treatment
  resuscitation may be provided

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Must Health Care Comply with POST Form?

• YES
• Providers can be disciplined by their licensing
  board for failure to honor advance directives or
  decisions of surrogate, provided provider had
  actual knowledge of directive
• Law protects good faith compliance with honoring
  Advance Directives

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Why POST Works

• By law MUST accompany patient
• Contains specifics
• It IS a physicians order no interpretation is
  needed and POST orders are to be followed

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Take-Home Messages (about POST Form)

• POST provides a better means to identify and
  respect patients wishes
• POST completions will improve end-of-life care
  throughout the system
• Use of POST will require communication to make it
  work in your community
• Wheres the POST form?
• www.tennessee.gov/health
• www.endoflifecaretn.org